Form Ds-4085 - Omb Application Form For Additional Visa Pages Or Miscellaneous Passport Services Page 4

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APPLICATION FOR ADDITIONAL VISA PAGES
OMB CONTROL NO. 1405-0159
OR MISCELLANEOUS SERVICES
OMB EXPIRATION DATE: 10-31-2016
ESTIMATED BURDEN: 20 MIN
Please Print Legibly Using Black Ink Only
Attention: Read WARNING on page 1 of instructions
Please select the 48 page option only if you prefer to add 48 visa pages in lieu of the standard 24 extra pages to
your passport book. The larger book is appropriate for those who anticipate very frequent travel abroad during
the passport validity period, and is recommended for applicants who have required the addition of visa pages in
the past.
NOTE: If pages have been added to your passport book previously, we may not be able to
accommodate your request.
48 Pages (non-standard)
VP1
VP2 DOTS Code
1. Name as Listed on Passport: Last
End. #
Exp.
First
Middle
2. Date of Birth (mm/dd/yyyy)
4. Place of Birth (City & State if in the U.S., or City & Country as it is presently known.)
3. Sex
M
F
-
-
6. Email Address (e.g., )
5. Social Security Number
7. Primary Contact Phone Number
-
-
-
-
@
8. Mailing Address: Line 1: Street/RFD#, P.O. Box, or URB.
Address Line 2: Clearly label Apartment, Company, Suite, Unit, Building, Floor, In Care Of or Attention if applicable. (e.g., In Care Of - Jane Doe, Apt # 100)
City
State
Zip Code
Country, if outside the United States
10. Permanent Address -
9. Current Passport Number
Apartment/Unit
If P.O. Box is listed under Mailing Address or if residence is different from Mailing
Street/RFD # or URB (No P.O. Box)
Issue date (mm/dd/yyyy)
State
Zip Code
City
11. Additional Contact Phone Number
12. Occupation (if age 16 or older)
13. Employer or School (if applicable)
Home
Cell
Work
14. Emergency Contact - Provide the information of a person not traveling with you to be contacted in the event of an emergency.
Name
Address: Street/RFD # or P.O. Box
Apartment/Unit
State
Zip Code
Relationship
City
Phone Number
15. Travel Plans
Departure Date (mm/dd/yyyy) Return Date (mm/dd/yyyy)
Countries to be visited
YOU MUST SIGN AND DATE THE APPLICATION IN THE DESIGNATED AREA BELOW
I declare under penalty of perjury all of the following: 1) I am a citizen or non-citizen national of the United States and have not, since acquiring U.S. citizenship or nationality,
performed any of the acts listed under "Acts or Conditions" on page three of the instructions of this application (unless explanatory statement is attached); 2) the statements made
on the application are true and correct; 3) I have not knowingly and willfully made false statements or included false documents in support of this application; 4) I have read and
understood the warning on page one of the instructions to the application form.
x
Date
Applicant's Legal Signature - age 16 and older
x
Mother/Father/Parent/Legal Guardian's Signature (if identifying minor)
FOR ISSUING OFFICE ONLY
Other:
Attached:
* DS 4085 C 08 2013 1 *
For Issuing Office Only
Visa Pg Fee
EF
Postage
Other
DS-4085 08-2013
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